Complete Preservation of the Mitral Valve Apparatus during Mitral Valve Replacement for Rheumatic Mitral Regurgitation in Patients with an Enlarged Left Ventricular Chamber
DOI:
https://doi.org/10.1532/HSF98.20121128Abstract
Background and Aims: The merits of retaining the subvalvular apparatus during mitral valve replacement (MVR) for chronic mitral regurgitation have been demonstrated in clinical investigations. This study was to investigate the feasibility of total preservation of the leaflet and subvalvular apparatus at the native anatomic position during MVR in a rheumatic population with enlarged left ventricular chamber.
Material and Methods: The techniques of valvular apparatus preservation used during MVR with or without aortic valve replacement were investigated in 128 patients with an enlarged left ventricular chamber suffering from rheumatic mitral regurgitation between October 2003 and December 2007. Seventy patients had the anterior leaflet and subvalvular apparatus excised but the posterior leaflet and subvlvular apparatus preserved during the mitral valve replacement (P-MVR group), and 58 patients had the anterior and posterior mitral leaflets and the subvalvalur apparatus completely preserved at the native anatomical position during the mitral valve replacement (C-MVR group). Echocardiography was performed preoperatively, at discharge, and after 3 months, 1 year, and 3 years to determine the left ventricular dimensions and function.
Results: There were 2 cases (3.4%) of early death in the C-MVR group, and there were 4 cases (5.7%) of early death in the P-MVR group. There were 3 cases of late death 1 year after surgery, of which 1 case in the C-MVR group was caused by congestive heart failure and the other 2 cases in the P-MVR group were due to sudden death. Both groups exhibited significant improvement (P < .05) in left ventricular function instantly and late postoperatively. The reduction of the left ventricular end-diastolic diameter was more significant in the C-MVR group as compared to the P-MVR group (P < .05). A statistically significant increase in fractional shortening (FS) occurred in the C-MVR group compared to the P-MVR group.
Conclusion: This study shows that complete mitral leaflet preservation at the native anatomical position during MVR is feasible in rheumatic patients with an enlarged left ventricular chamber and confers significant short-term and long-term advantages by preserving left ventricular function and geometry. Therefore, it is a safe, simple, and effective surgical technique and should be individualized during clinical use.
References
Akins CW, Miller DC, Turina MI, et al. 2008. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg 135:732-8.nAlsoufi B, Al-Shahid M, Manlhiot C, et al. 2010. Mitral valve replacement with the Quattro stentless pericardial bioprosthesis: mid-term clinical and echocardiographic follow up. J Heart Valve Dis 19:304-11.nAthanasiou T, Chow A, Rao C, et al. 2008. Preservation of mitral valve apparatus: evidence sythesis and critical reappraisal of surgery techniques. Eur J Cardiothorac Surg 33:391-401.nBatista RJ, Verde J, Nery P, et al. 1997. Partial left ventriculectomy to treat end-stage heart disease. Ann Thorac Surg 64:634-8.nChowdhury UK, Kumar AS, Airan B, et al. 2005. Mitral valve replacement with and without chordal preservation in a rheumatic population: serial echocardiographic assessment of left ventricular size and function. Ann Thorac Surg 79:1926-33.nCingöz F, Günay C, Kuralay E, et al. 2004. Both leaflet preservation during mitral valve replacement: modified anterior leaflet preservation technique. J Card Surg 19:528-34.nDavid TE, Uden DE, Strauss HD. 1983. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation 68:II76-82.nGarcía-Fuster R, Estevez V, Gil O, Cánovas S, Martínez-Leon J. 2008. Mitral valve replacement in rheumatic patients: effects of chordal preservation. Ann Thorac Surg 86:472-81.nHosono M, Shibata T, Sasaki Y, et al. 2008. Left ventricular rupture after mitral valve replacement: risk factor analysis and outcome of resuscitation. J Heart Valve Dis 17:42-7.nJacob R, Dierberger B, Kissling G. 1992. Functional significance of the Frank-Starling mechanism under physiological and pathophysiological conditions. Eur Heart J 13:7-14.nOkamoto K, Kiso I, Inoue Y, Matayoshi H, Takahashi R, Umezu Y. 2006. Left ventricular outflow obstruction after mitral valve replacement preserving native anterior leaflet. Ann Thorac Surg 82:735-7.nSasaki H, Ihashi K. 2003. Chordal-sparing mitral valve replacement: pitfalls and techniques to prevent complications. Eur J Cardiothorac Surg 24:650-2.nStraub UJ, Huwer H, Kalweit G, Volkmer I, Gams E. 1997. Improved regional left ventricular performance in mitral valve replacement with orthotopic refixation of the anterior mitral leaflet. J Heart Valve Dis 6:395-403.nYousefnia MA, Mandegar MH, Roshanali F, Alaeddini F, Amouzadeh F. 2007. Papillary muscle repositioning in mitral valve replacement in patients with left ventricular dysfunction. Ann Thorac Surg 83:958-63.nYun KL, Sintek CF, Miller DC, et al. 2002. Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: effects on left ventricular volume and function. J Thorac Cardiovasc Surg 123:707-14.n
